Question

question 20

a provider visits mr. smiths home monthly. today, the provider performs a medically appropriate history and examination. the provider orders cbc, blood iron level, level for b12, and folate lab tests. what is the level for the amount and/or complexity of data to be reviewed?

moderate
straightforward
high
low

Explanation:

Identify the ordered tests

The provider orders 4 unique laboratory tests:

1. CBC (Complete Blood Count)
2. Blood iron level
3. Vitamin B12 level
4. Folate level

Determine the MDM data category requirements

Under the CPT Evaluation and Management (E/M) guidelines for the "Amount and/or Complexity of Data to be Reviewed and Analyzed" component of Medical Decision Making (MDM):

• Category 1 (Tests and documents) requires meeting a combination of at least 2 of the following:
• Review of prior external note(s)
• Review of the result of each unique test
• Ordering of each unique test
• Assessment requiring an independent historian
• Ordering 3 or more unique tests satisfies the requirement for a "Moderate" level of data complexity (which requires at least 3 points from Category 1).

Classify the final data complexity level

Since 4 unique tests are ordered (which is $\ge 3$), the level of data to be reviewed and analyzed is classified as Moderate.

Answer:

• Moderate (Correct answer)
• Straightforward
• High
• Low